Rotator Cuff Tears: Imaging, Rehab, and Surgical Repair

Most people think of a rotator cuff tear as something that happens to athletes or weightlifters. But the truth? Rotator cuff tears are far more common than you think - especially after 40. In fact, over half of people over 60 have a tear in their shoulder without even knowing it. No pain. No symptoms. Just a worn-out tendon. So if you’re dealing with shoulder pain, stiffness, or weakness when lifting your arm, it’s not just "getting older." It could be a rotator cuff tear - and knowing how to diagnose and treat it properly makes all the difference.

How Doctors Spot a Rotator Cuff Tear

Before any scan, your doctor will start with your hands. That’s right - physical exams still come first. They’ll move your arm in specific ways to test for pain and weakness. Tests like the Empty Can, Neer impingement, and Hawkins-Kennedy aren’t just random moves. They’re proven ways to find which tendon is damaged. If you feel sharp pain when your arm is lifted overhead, or if you can’t hold your arm out to the side without it dropping, those are red flags.

But here’s the catch: physical exams alone can’t tell you the size or depth of the tear. That’s where imaging comes in. The first imaging test? X-ray. It doesn’t show tendons, but it shows bone. Are there bone spurs? Is the joint arthritic? Is the shoulder aligned right? These details change how you treat the tear. Over 90% of patients get an X-ray before anything else.

Now, for the actual tear - that’s where MRI and ultrasound come in. Both can see soft tissue. MRI gives you a detailed, high-res picture of the whole shoulder. It shows if the tear is partial or full-thickness, how big it is, and even if the muscle has started to waste away. MRI is accurate about 92% of the time for full-thickness tears. But it’s expensive - often $500 to $1,200 - and you can’t use it if you have metal implants like pacemakers or joint replacements.

Ultrasound is the quiet alternative. It’s cheaper - around $200 to $400 - and you can watch the tendon move in real time. If you lift your arm and the tendon snaps or doesn’t glide smoothly, the ultrasound catches it. Studies show it’s 87% to 91% accurate for full-thickness tears. Patients prefer it too. In one survey, 92% chose ultrasound over MRI because it’s faster, quieter, and doesn’t feel like being locked in a tube.

But ultrasound has a downside: it’s only as good as the person holding the probe. Only 45% of general radiologists are trained to read shoulder ultrasounds well. If your clinic doesn’t have a specialist, you might miss a small tear. That’s why MRI is still the gold standard for surgical planning. If your doctor thinks you need an operation, they’ll likely order an MRI to map out the damage before cutting.

Rehab: Can You Fix It Without Surgery?

Here’s the good news: most people don’t need surgery. About 85% of those with partial-thickness tears get better with rehab alone. Even some full-thickness tears - especially in older or less active people - can be managed without an operation.

Rehab isn’t just doing stretches. It’s a step-by-step process that takes months. Phase one (weeks 1-6) is all about protecting the shoulder. No lifting. No reaching. Just passive movement - someone else moves your arm for you to keep the joint loose. This prevents stiffness without stressing the tear.

Phase two (weeks 6-12) adds active-assisted motion. You start using your own muscles, but with help - resistance bands, pulleys, or even your other arm. The goal? Regain full range of motion without pain.

Phase three (after week 12) is strengthening. This is where you rebuild the rotator cuff muscles: supraspinatus, infraspinatus, teres minor, subscapularis. Exercises like external rotation with a band, scapular squeezes, and wall push-ups are key. It’s slow. It’s boring. But skipping this phase is why some people get worse after rehab.

Studies show that people who stick with rehab for at least 3 months have a 70% higher chance of avoiding surgery. And if you’re over 65, your odds of success without surgery are even better. The American Academy of Orthopaedic Surgeons now recommends trying 6 to 8 weeks of physical therapy before ordering an MRI - because many tears are just part of aging, not emergencies.

Surgery: When and How It’s Done

Surgery isn’t a last resort - it’s a smart choice for the right person. If you’re under 65, active, and have a full-thickness tear that’s causing real weakness or pain, surgery often gives the best long-term result. The type of surgery? Almost always arthroscopic. In 90% of cases today, surgeons use small cameras and tiny instruments to repair the tendon through 3-4 half-inch incisions.

Arthroscopic repair has replaced open surgery because it’s less invasive. Recovery is faster. Infections are rarer. Complication rates are about 30% lower than with open surgery. And you’re back to daily tasks like dressing or driving sooner - often within 4 to 6 months instead of 8 to 12.

During the procedure, the surgeon cleans up frayed edges, removes bone spurs that were rubbing on the tendon, and reattaches the torn tendon to the bone using small anchors. These anchors hold the tendon in place while it heals - like stitches in a torn shirt, but buried in bone.

For massive tears - over 3 centimeters - things get trickier. The tendon may be too short or too weak to reattach. That’s when surgeons might use a patch graft or try to transfer another tendon. These are complex cases, and success rates drop. About 27% of large tears retear after surgery, compared to just 12% for small ones.

There’s also talk about PRP (platelet-rich plasma) injections during surgery to speed healing. But the evidence is shaky. The Cochrane Review found only moderate benefit - not enough to make it standard. Same with stem cell injections. They’re trendy, but not proven.

What Happens After Surgery?

Post-op rehab is just as important as the surgery itself. Gone are the days of wearing a sling for 6 weeks. Today, most patients start gentle passive motion the day after surgery. Why? Early movement prevents scar tissue from locking the joint. But you still can’t lift, push, or pull for 3 months.

Weeks 1-6: Passive motion only. Physical therapist moves your arm. You do pendulum swings and gentle stretches.

Weeks 6-12: Active motion begins. You start moving your arm on your own, with light resistance.

Weeks 12-24: Strengthening. Band exercises, light weights, scapular control. No overhead lifting until 4-6 months.

Full recovery? Most people feel 80% better by 6 months. But the tendon takes a full year to fully heal. That’s why you can’t rush back to tennis, lifting, or manual labor too soon. Retear risk is highest between 3 and 6 months - right when people start feeling good and think they’re done.

Long-Term Outcomes: What to Expect

Five years after surgery, 82% of patients say they’re happy with the result. Pain is down. Strength is up. Sleep is better. But not everyone gets back to full function. Retears happen. Muscle atrophy can set in. And if you had a big tear to begin with, you might never regain 100% strength.

That’s why prevention matters. Keep your rotator cuff strong. Do regular shoulder stability exercises. Avoid repetitive overhead motions if you’re over 50. If you feel a dull ache after gardening or painting, rest it. Don’t push through pain.

And if you’re told you need surgery - get a second opinion. Ask if rehab has been tried. Ask what size the tear is. Ask if your muscle quality looks good on the MRI. Those details change everything.

What’s Next in Rotator Cuff Care?

The field is changing fast. AI is starting to help read MRIs. A 2023 study showed deep learning algorithms could tell partial from full-thickness tears with 89% accuracy - faster and more consistent than some radiologists. That could mean quicker diagnoses and fewer missed tears.

Ultrasound is also getting smarter. New handheld devices are now used by orthopedic surgeons in clinics, not just radiologists. You walk in, get scanned right away, and get results before you leave the room.

One thing won’t change: the importance of matching treatment to the person. A 70-year-old gardener with a small tear doesn’t need the same treatment as a 45-year-old carpenter with a large tear. The goal isn’t just to fix the tendon - it’s to get you back to your life.